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Free Planned Parenthood Proof Template

The Planned Parenthood Proof form is a document designed for individuals seeking medical services related to pregnancy testing and reproductive health. It collects essential personal information and medical history to ensure appropriate care and confidentiality. Completing this form is a crucial step in accessing the services provided by Planned Parenthood Southeastern Virginia.

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Table of Contents

The Planned Parenthood Proof form is an essential document that facilitates a patient's access to reproductive health services while ensuring their rights and privacy are respected. This form is used primarily for individuals seeking a urine pregnancy test, and it includes several critical sections designed to gather personal and medical information. Patients are required to provide their contact details, including names, addresses, and phone numbers, which are crucial for maintaining communication, especially when discussing test results. The form emphasizes confidentiality, allowing patients to choose their preferred method of contact, whether by phone or mail. Additionally, it collects information about the patient's medical history, current symptoms, and reasons for seeking a test, which helps healthcare providers deliver personalized care. A section dedicated to patient education outlines the importance of understanding the tests and treatments available, ensuring that patients are well-informed and empowered to make decisions regarding their health. Furthermore, the form includes a consent statement, affirming that patients acknowledge their rights and the privacy practices of Planned Parenthood. This comprehensive approach not only streamlines the medical service request process but also fosters a supportive environment for individuals navigating sensitive health decisions.

Document Specifics

Fact Name	Description
Confidentiality Commitment	Planned Parenthood of Southeastern Virginia is dedicated to maintaining patient confidentiality. They may contact patients through phone calls, email, text, or mail, particularly to communicate results of abnormal tests.
Patient's Bill of Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities and the Patient Complaints policy upon request, ensuring they are informed of their rights during their visit.
Language Services	Patients are informed that language interpreter services may be necessary for understanding health care information. While free services may not always be available, Planned Parenthood will refer patients to other facilities if needed.
Reporting Requirements	If tests for sexually transmitted infections yield positive results, reporting to public health agencies is mandated by law. This ensures compliance with public health regulations.

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Free Planned Parenthood Proof File

Planned Parenthood Proof Example

PLANNED PARENTHOOD® OF SOUTHEASTERN VIRGINIA

403 Yale Drive, Hampton, VA 23666 (757)826-2079

515 Newtown Road, Virginia Beach, VA 23462 (757)499-7526

PLEASE PRINT LEGIBLY

URINE PREGNANCY TEST

 (PLEASE CHECK) I have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy

Last Name:

First Name:

Middle Initial:

Address:

Apt #

City:

State:

Zip Code:

Employer:

Email address: (cannot be used for test results)

Home Phone #:

Cell Phone #:

Work Phone #:

Emergency Contact Name:

Phone Number:

We are committed to maintaining your confidentiality. At times it is necessary for us to contact you, usually with the

results of an abnormal test, through phone calls, email, text &/or mail (plain white envelope)

Please check the methods we can use to contact you? Phone Call

Mail

Please provide a password to receive test results over the phone____________________

Date of Birth

Sex  Female

 Transgender

Monthly Income

Family Size Supported By

Pronoun you like:  She  Other ____

Income

Do you have a living will?

 Yes

No

How did you hear about us?  AD (circle)

Billboard

Phonebook

Radio

Newspaper/Magazine

 Other Planned Parenthood

 Doctor

Family

Friends

School

Online

Facebook

Race

 Caucasian

 American Indian/Alaskan

Multiracial

Ethnicity

 African American

 Asian

 Pacific Islander

Other

Hispanic? Yes  No

Highest Level Of Education Completed  Middle School

 High School Some College

Bachelors/Masters/PhD

MEDICAL SCREENING (COMPLETED BY CLIENT)

1st day of last menstrual period __________

Was it normal?  Yes  No If no, explain:______________________

Reason for Test

 Planned Pregnancy  Contraceptive Failure  No Regular Birth Control

Test Results You Hope To See

 Negative

 Positive

 Doesn’t matter

Yes

Are you currently experiencing?

Yes

Are you currently using birth control?

Spotting/Bleeding

Fever

If yes, what method? ___________________

Abdominal Pain

For how long?

Vomiting

Do you have a history of?

Yes

Abnormal Bleeding

Would you like to discuss problems related to a

Ectopic Pregnancy

rape or emotional/physical/sexual abuse?

Missed or Spontaneous Abortion (Miscarriage)

Has your partner ever messed with your birth control or tried to

Pelvic Infection

get you pregnant when you didn’t want to be?

Are you currently experiencing any signs or

Does your partner refuse to use a condom when you ask?

symptoms of pregnancy?

Has your partner ever tried to force or pressure you to become

If yes, explain:

pregnant when you didn’t want to be?

Are you afraid of your partner?

ASSESSMENT (COMPLETED BY CLINIC STAFF)

Gravida

Para

Live Births

Spontaneous Abortion __ __ Elective Abortion_ ___ Living children _ __

Urine high-sensitivity HCG Pregnancy Test Order/Result:  Negative Positive (EDC:_______EDD:________)  Indefinite

Patient Education				V	H		V	H	For NEGATIVE Results-
V=Verbal H=Handout			CIIC EC			CIIC Pregnancy Tests			 Explained limitations of test (morning urine
	V	H	CIIC HOPE			STIs			sample/time since last period)
	V	H	CIIC HOPE			STIs			 Advised re-test in 1-2 weeks
BCM Options			CIIC Contraceptive Implant			Prenatal Care			 Advised re-test in 1-2 weeks
BCM Options			CIIC Contraceptive Implant			Prenatal Care			 Discussed blood PT
CIIC Pill,Patch, Ring			CIIC IUC			Adoption			 Discussed blood PT
CIIC Pill,Patch, Ring			CIIC IUC			Adoption			 Advised RTO if no menses for 3 consecutive
CIIC DMPA			CIIC Barriers (condoms)			Abortion			months
CIIC POPs			CIIC Essure			CI Sx of Early Pregnancy			If Minor: Encouraged parental involvement
Intake Staff Signature:						Date:
Licensed Qualified Staff Signature:						Date:

Revised March 2014

Request for Medical Services and Acknowledgement of Receipt of Notice of Health Information Privacy Practices I-B-2a Revised June 2012

PLANNED PARENTHOOD® OF SOUTHEASTERN VIRGINIA

403 Yale Drive, Hampton, VA 23666 (757)826-2079

515 Newtown Road, Virginia Beach, VA 23462 (757)499-7526

REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

DATE _______________________________

PATIENT LABEL

Before you give your consent, be sure you understand the information given below. If you have any questions, we will be happy to talk about them with you. You may ask for a copy of this form.

I understand that I must tell the staff if language interpreter services are necessary to my understanding of the written or spoken information given during my health care visits. I understand that free interpretive services may not be immediately available and Planned Parenthood may need to refer me to another health care facility to provide the services necessary for my care.

I understand that the information I will provide is true, accurate, and complete and that my healthcare choices will depend on that information.

I will be given information about the test(s), treatment(s), procedure(s), and contraceptive method(s) to be provided, including the benefits, risks, possible problems/complications, and alternate choices. I understand that I should ask questions about anything I do not understand. I understand that a clinician is available to answer any questions I may have.

Please note that Planned Parenthood Southeastern Virginia is a teaching institution, and that persons in training, under strict supervision, may be involved in some aspects of your care.

No guarantee has been given to me as to the results that may be obtained from any services I receive. I know that it is my choice whether or not to have services. I know that at any time, I can change my mind about receiving medical services at Planned Parenthood.

I understand that if tests for certain sexually transmitted infections are positive, reporting of positive results to public health agencies is required by law.

I will be given referrals for further diagnosis or treatment if necessary. I understand that if referral is needed, I will assume responsibility for obtaining and paying for this care. I will be told how to get care in case of an emergency.

I understand that confidentiality will be maintained as described in Planned Parenthood Southeastern Virginia Notice of Health Information Privacy Practices. I consent to the use and disclosure of my health information as described in Notice of Health Information Privacy Practices.

I hereby request that a person authorized by Planned Parenthood provide appropriate evaluation, testing, and treatment (including a birth control drug or device, if I request it).

I hereby acknowledge receipt of Planned Parenthood Southeastern Virginia notice of health information privacy practices.

Signature of patient __________________________________________________________ Date _______________

I witness the fact that the patient received the above mentioned information and said she/he read and understood same and had the opportunity to ask questions.

Signature of witness _________________________________________________________ Date _______________

CHECK HERE IF PATIENT'S GUARDIAN OR RELATIVE IS LEGALLY REQUIRED TO SIGN BELOW

Signature of any other person consenting ____________________________________

Relationship to patient ___________________________________________________

Date _______________

I witness the fact that the patient's legal guardian (or person consenting in her behalf) received the above mentioned information and said she read and understood same.

Signature of witness _____________________________________________________

Date _______________

Understanding Planned Parenthood Proof

What is the Planned Parenthood Proof form used for?

The Planned Parenthood Proof form is primarily used for individuals seeking medical services related to pregnancy testing and reproductive health. By filling out this form, patients provide essential information that helps healthcare providers understand their medical history, current health status, and specific needs. This information is vital for delivering accurate care and ensuring that patients receive appropriate guidance regarding their reproductive health options.

How do I ensure my information remains confidential?

Planned Parenthood is committed to maintaining your confidentiality. The form includes a section where you can specify how you prefer to be contacted regarding test results—whether by phone or mail. Additionally, any communication regarding your health will be handled with discretion, often using plain envelopes for mailed correspondence. It’s important to provide accurate contact preferences and inform the staff of any special requests regarding your privacy.

What should I do if I have questions while completing the form?

If you have questions while filling out the Planned Parenthood Proof form, don’t hesitate to ask the staff for clarification. They are there to assist you and ensure you understand each section of the form. You can inquire about any medical terms or specific questions related to your health or the services you are seeking. Remember, it’s crucial to provide accurate and complete information for the best care possible.

Can I change my mind about receiving services after submitting the form?

Yes, you have the right to change your mind about receiving medical services at any time, even after submitting the Planned Parenthood Proof form. Your healthcare choices are entirely yours, and you can discuss any concerns or hesitations with the clinic staff. They will provide you with the necessary information and support to make informed decisions about your health care.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, follow these guidelines to ensure accuracy and clarity:

Print legibly. Ensure all information is clear and easy to read.
Provide accurate personal details. Double-check your name, address, and contact information.
Use a secure password. This will help protect your test results when receiving them over the phone.
Indicate your preferred contact method. Choose how you would like to be contacted regarding your results.
Be honest about your medical history. This includes any current symptoms or past medical issues.
Ask questions. If you do not understand something, seek clarification from staff.
Keep a copy of the form. Retain a copy for your records after submission.
Be mindful of confidentiality. Understand how your information will be used and protected.
Complete all sections. Ensure no fields are left blank unless specified.
Review before submission. Check for any errors or missing information.

Additionally, avoid these common mistakes:

Do not rush through the form. Take your time to ensure accuracy.
Do not provide false information. Honesty is crucial for your care.
Do not skip the emergency contact section. This information is important.
Do not forget to sign the form. An unsigned form may delay your services.
Do not ignore the instructions for minors. Parental involvement may be necessary.
Do not assume confidentiality is guaranteed without understanding the policies.
Do not leave out your preferred pronouns. This helps staff address you correctly.
Do not overlook the importance of your income information. It may affect your care options.
Do not hesitate to ask for help if needed. Staff are available to assist you.
Do not forget to mention any special needs, such as language interpretation.

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